I am never content until I have constructed a mechanical model of the subject I am studying. If I succeed in making one, I understand. Otherwise, I do not.
Adopting accurate organizational solutions in planning healthcare services is essential, especially when dealing with patients as vulnerable as the elderly. Even after appropriate treatment for the condition that required hospital admission, older adults are often discharged with a new disability that was not present at baseline (see Chapter 42), or are going to experience functional impairment in the year following hospital discharge.
Studies in the 90s (Kellogg et al. 1991, Tierney and Worth 1995) reported in older patients both living at home and in community dwellings that the probability of suffering from a new disability after hospital discharge was 35% or more. Both patient-related (associated illnesses, cognitive impairment, poly-medication, etc.) and hospital-related conditions (reduced mobility, inappropriate drug administration, malnutrition, etc.) were found to be risk factors. As these were at least partially modifiable, preventive strategies based on their close control were hypothesized and in the last 30 years a variety of clinical pathways (CPs) and models of care (MoCs) dedicated to older hospitalized patients have been designed worldwide, some of them specifically intended for surgical care.
Hospital-related complications in the elderly can be very serious and life-threatening; these include delirium, infection, falls, pressure sores, malnutrition, loss of independence, intestinal and urinary dysfunction, cognitive deterioration, social isolation, nursing home placement and mortality. In addition, associated costs are significant for patients, their families, healthcare institutions and society as a whole.
A consistent body of evidence accumulated over the last 25 years supports the concept that reducing variation in healthcare services by process standardization and protocol implementation contributes to minimizing the probability of medical errors, while optimizing care cost-effectiveness (Kohn et al. 1999).
Guidelines implementation, introduction of Continuous Quality Improvement principles and increased attention on patient expectations has marked a further advancement in healthcare delivery. More recently, MoCs were introduced as a paradigm for implementing care cycles in the treatment of specific patient groups; they can be regarded as a synthesis of high-quality care standards, effective management of both human and material resources and a comprehensive approach to patient needs.
Tracing origin and evolution of MoCs over the time is not easy; different terms are in fact interchangeably used to indicate them (models of care, clinical pathways, nursing models, paradigms, case management plans, etc.) and no univocal shared definition exists. Over the years, inputs from different fields – in part derived from the industrial world, in part conceived by nursing theorists, but all originating from the same methodological matrix “assess–plan–implement–evaluate” cycle – contributed to their definition.
Patient care teams (PCTs), introduced in nursing care following World War II and based on effective communication, combined skills and delegation, can be considered precursors of clinical pathways (CPs). Further nursing models of care (primary nursing, individual patient allocation, functional nursing and team nursing) were defined later (Fairbrother et al. 2015). CPs were introduced in the early 1980s in the United States and systematically used since 1985 at the New England Medical Center in Boston, in response to the introduction of the diagnosis-related group (DRG) system, which assigned a reference length of stay to each DRG (Vanhaecht et al. 2007). Interdisciplinary team (IDT) rounds and geriatric evaluation and management (GEM) units (these latter firstly implemented at Veterans Affairs Medical Centers) can be considered precursors of MoCs for geriatric surgery.
An MoC can be intended as an institutional policy that defines the way health services are delivered, states evidence-based principles and best practices on which internal organization is based and aims to reduce preventable complications through high levels of care, delivered at the right time, by the right team and in the right location.
CPs and MoCs are used to reduce discomfort and complications in hospitalized patients through unitary answers to their needs, increase both appropriateness and effectiveness of care, and promote integration and cooperation among staff. Instruments are guidelines, procedures, protocols and agreements. Other elements are evidence-based preventive strategies toward functional decline, delirium and geriatric syndromes. Staff availability to debate practices will help in obtaining a shared vision and scope.
Planning of adequate care after discharge (see Chapter 43) should be considered intrinsic to MoCs goals. Specific design criteria for structure, together with implementation of project management criteria represent indispensable elements.
Activating an MoC is a complex task, somewhere between a scientific and a socio-economical duty. The decision-making process will start quickly, whereas results will be conditioned by many factors; however both will be deeply influenced by the level of culture, either scientific or managerial, staff are able to express. Cohesion among the different levels of organization, mutual accountability and open-mindedness are essential components.
Central to MoCs are the following elements (Vanhaecht et al. 2007):
To get the best results, a solid, appropriate knowledge of medical, relational and ethical aspects of geriatric care should be integrated by elements from systems engineering and business theory (see Chapter 49).
The NSW Agency for Clinical Innovation (ACI 2013) issued a practical guide on how to develop an MoC. The document synthetizes the state-of-the-art and offers concrete indications on how to proceed in implementing it, in respect of some well-established, evidence-based guiding principles. In summary, an MoC:
has localized flexibility and considers equity of access
supports integrated care, efficient resource utilization, and both safety and quality of care
evaluates outcome and processes by standardized sets of measures
is innovative and prepared for future developments.
Other aspects to consider concern are how the MoC links to local resources and current initiatives, in order to allow the maximum degree of integration and create a continuum of activity flows from the structure to patients and their families.
Surgery in the elderly has seen a significant increase in the last 15 years, due to both the growing number of patients and expanded methodological and technical knowledge. The most frequently performed surgery among the elderly is hip fracture repair (see Chapter 24). Its frequency increased impressively along with population aging and its occurrence is currently regarded worldwide as a sort of epidemic. Hip fracture usually occurs in multimorbid and complicated patients and requires urgent surgery; both postoperative complications and mortality are high. This has stimulated clinicians to define strategies that –combining abilities and knowledge from different specialties – could improve results; coupling surgical skills (anesthetists and orthopedists in primis) together with internal medicine competences (geriatricians, geriatric nurses, hospitalists), the first orthogeriatric units were developed. Historically, the prototype was introduced by Cosin (1954) in the UK.
In recent years a number of MoCs for geriatric surgery have been developed in many countries. It has mostly been in the US that they have seen the widest expansion; however, their development in European countries has also increased in recent years. Consistent differences exist between countries as far as the type of internal medicine specialists enrolled in the team, the way they intervene in the care process and the adopted organizational criteria.
In this MoC, elderly patients are admitted to a surgical ward, where surgeons are in charge of their treatment. With geriatric consultation, a team of physicians, social workers and nurses experienced in geriatrics applies a systematic approach, including a comprehensive assessment of physical, emotional and functional status (CGA, see Chapter 2) and provides plans on how to prevent common geriatric complications and admission-related functional impairment. This approach aims to improve the clinical course by reducing hospital-acquired complications such as delirium, falls or functional decline through implementation of appropriate treatment.
In the years 1980–2000, this MoC attracted great interest in the literature. However, although early studies showed encouraging results, in light of the numerous subsequent studies, this model proved to be ineffective compared to usual care (Stuck et al. 1993, Ellis 2011). The lack of systematic control of implementation of the team’s indications seems to be its main intrinsic limiting factor.
The organizational structure consists of separated wards where, regardless of the condition requiring hospitalization, elderly patients are admitted. A first example was realized in the 1970s within the Veterans Administration Hospitals in the USA. The main features of this MoC are:
dedicated staff perform interdisciplinary team rounds
patient-centered conferences involving family/caregivers are regularly organized
the physical environment is ensured, aiming at reducing discomfort (enhanced lighting, flooring to decrease glare and noise) and promoting functional independence (living room areas, socialization, cognitive stimulation activities).
The main goals are maintaining preadmission function, preventing/reducing falls, pressure sores, delirium, cognitive decline, immobility and constipation, and minimizing the use of physical restraints and Foley catheters.
Robust evidence indicates that, compared with usual care, this model is effective in reducing functional decline, inappropriate medication, postdischarge institutionalization and death (Baztan 2009, Van Craen 2010, Ellis 2011).
In these MoCs, a multidisciplinary, multiprofessional team, mainly composed of physicians, surgeons, anesthetists, physiotherapists, nurses and social workers, cooperates within a shared pathway. Team tasks include patient assessment at admission, treatment of associated illnesses, communication with both surgeons and family, and facilitation at discharge, with special attention on home care or assisted home placement.
Comanagement-based MoCs are conceptually and historically linked to hip fracture treatment, and ortho-geriatric units represent a classical example of such approach. Based on this model, experiences have been positive in many institutions and in many different countries.
In its most common form, comanagement is led by geriatricians. Examples of this MoC are POPS (Proactive Care of Older People undergoing Surgery) at Guy’s and St. Thomas’ Hospital in London and SCOPUS (Systematic care of Older Patients Undergoing Elective Surgery) in Nottingham. Hospitalist-led variants re found in countries where such a specialism exists (Australia).
Strong evidences indicates that cocare models are effective in reducing mortality and improving both short- and long-term outcomes in older surgical patients (Vidan 2005). However, integrated multidisciplinary and multiprofessional cocare models are complex systems, where several key points combine to determine the final outcomes. This pattern makes their ultimate effectiveness difficult to assess with the currently available statistical tools (Campbell et al. 2000, Pioli et al. 2012) and deciding on their implementation on a massive scale remains a debatable issue.
Adequate Patient Evaluation
A principle that clearly emerges from literature analysis is that Comprehensive Geriatric Assessment (CGA, see Table 45.1) represents a pivotal element in the organizational structure of MoCs. There are various versions of the CGA, but no standard model exists. As was illustrated in Section 1, elderly patients are an inhomogeneous group and CGA implementation, which allows individual-based evaluation of their functional status (FS), marked a milestone in the history and evolution of geriatric medicine. No Geriatric MoC can exist without this key element.
|– Physical health status (CIRS)|
|– Cognition (MMSE)|
|– Sensorial evaluation|
|– Psycho-emotional status (GDS)|
|– Preserved abilities (BADL/IADL)|
|– Nutrition (MNA)|
|– Socio-economical issues|
|– Medication evaluation|
Evidence accumulated in recent years indicates that, independent of the setting where it is performed, CGA and medication review can contribute to minimizing functional impairment and to reducing a variety of hospital-related complications in older surgical patients. The main issue that CGA addresses in perioperative care of the elderly is timely identification of risk factors for perioperative complications, in order to plan and implement preventive evidence-based strategies.
It is important to emphasize that CGA should not be considered just a “snapshot,” a portrait of the patient’s current condition. Instead, it should be considered a “photogram” of the movie representing how the patient’s condition evolves with time and, particularly, during the hospital stay.